Cite this article: Jake Halvorsen GDO, Richmond L, Martus W, Pena M, Katherine Pitus DO, et al. (2017) HEDIS Criteria for Lower Back Pain and Early Intervention and Imaging Utilization in the Emergency Department Observation Unit. Arch Emerg Med Crit Care 2(2): 1023.
*Corresponding authorJake Halvorsen, Department of Emergency Medicine, St. John Macomb-Oakland Hospital, 11800 E Twelve Mile Rd, Warren, MI, 48093, USA, Tel: 248-967-7425; Fax: 248-967-7794; Email:
Keywords•Low back pain•HEDIS measures•Observation unit
Research Article
HEDIS Criteria for Lower Back Pain and Early Intervention and Imaging Utilization in the Emergency Department Observation UnitJake Halvorsen GDO1*, Lindsay Richmond2, Wesley Martus1, Margarita Pena2, Katherine Pitus DO1, Antonio Bonfiglio1, and Victor Coba1,2
1Department of Emergency Medicine, St. John Macomb-Oakland Hospital, USA2Department of Emergency Medicine, St. John Hospital and Medical Center, USA
Abstract
Introduction: Our goal was to assess the Healthcare Effectiveness Data and Information Set (HEDIS) criteria in the utilization of resources in patients with lower back pain in the emergency department observation units of two hospitals.
Methods: We reviewed the electronic medical records of all patients placed in the emergency department observation unit of two hospitals between January 1, 2013 and December 31, 2013 for factors related to the current HEDIS measures and other historical and demographic factors.
Results: During the study period, 280 study patients were identified, 106 (37.9%) meeting the current HEDIS criteria. These patients and those without current HEDIS criteria were as likely to have MRI (49% vs 39%, p=0.08) and early procedural intervention (22% vs 16%, p=0.19). Increased rate of intervention was associated with personal history of back surgery (N=69, 30.4% intervention, p=0.002) and pain score 10/10 (N=117, 22.7% intervention, p=0.04). Higher risk was seen in patients with modified criteria with the addition of history of back surgery (N=143, 24% intervention, p=0.02), particularly with a score of 2 or more as well as pain 10/10 (n=21, 52.4% intervention, p <0.000001).
Conclusion: We found no statistically significant difference in utilization of MRI or intervention in patients meeting current HEDIS criteria. Personal history of back surgery and pain score 10/10 were associated with increased utilization. A Modified HEDIS criteria including personal history of back surgery was found to have increased utilization with a highest risk group of two or more Modified HEDIS criteria as well as pain score 10/10.
ABBREVIATIONS ED: Emergency Department; EDOU: Emergency Department
Observation Unit; HEDIS: Healthcare Effectiveness Data and Information Set; CT: Computed Tomography; MRI: Magnetic Resonance Imaging
INTRODUCTIONBack pain is a pervasive complaint among patients in all
healthcare settings and is the 6th most common presenting complaint in emergency department (ED) [1]. Back pain can lead to substantial morbidity including chronic pain, work absenteeism, and disability, and is a leading cause of disability in the United States [2]. In addition, medical costs such as hospitalization, specialist consultation [3], advanced imaging, and surgical and procedural interventions may occur. Causes of back pain [4] have been extensively described to help guide research [5] (Figure 1),
clinical management, and understanding prognosis [6]. Special concerns have been given to the increasing prevalence [7] of back pain in the aging population as well as weighing compassion for patient’s pain, which may be underestimated by physicians [8] and weighed against the contribution of chronic back pain to the epidemic of opioid misuse and abuse [9].
ED patients with back pain may be placed in an ED observation unit (EDOU) as an alternative to inpatient hospital admission or ED discharge for further treatment and evaluation with diagnostic imaging [10,11], and/or consultation (Figure 2). In the era of cost control and appropriate use, the Choosing Wisely Campaign identified lower back pain as an area for improvement to standardize radiographic utilization and to contain costs in the ED and ED observation unit. Guidelines to help reduce inappropriate use of advanced imaging have shown to decrease costs significantly [12] by decreasing testing on self-limited processes that could effectively be treated conservatively
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on an outpatient basis with delayed imaging [13].
The Agency for Healthcare Research and Quality recommends the Healthcare Effectiveness Data and Information Set (HEDIS) criteria to guide radiographic utilization and to identify serious back pathology that may or may not need intervention. The current HEDIS criteria include medical history of cancer, recent
trauma within 1 year, and history of intravenous drug abuse within 1 year, and neurologic impairment. This retrospective cohort compared patients meeting criteria for positive HEDIS to usual care in the absence of formal education initiatives or requirements of the use of HEDIS criteria. We hypothesized that adults placed in observation meeting HEDIS criteria would
Figure 1 Resource Utilization in Current HEDIS Criteria. Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer.
Figure 2 Resource Utilization in Modified HEDIS Criteria. Modified Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer, Personal History of Back Surgery.
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have greater use of imaging, consultation and intervention as compared to those with usual care. The primary objective was to evaluate factors related to acute lower back pain not included in the current HEDIS criteria that are related to MRI imaging, resource utilization and early procedural or surgical intervention within 30 days (Figure 3).
MATERIALS AND METHODSThis was a multi-center retrospective cohort chart review of
all ED patients placed in an observation unit with a diagnosis of acute low back pain between January 1, 2013 and December 31, 2013. The centers were an urban hospital with 125,000 ED visits a year and a community hospital with 70,000 ED visits a year. Both hospitals are academic sites staffed by board certified ED physicians in both the ED and EDOU. This study was approved by the institutional review board (IRB) as expedited research with waiver of informed consent.
Inclusion criteria included adults aged greater than 18 presenting to the ED with a chief complaint of acute low back pain who were placed in the EDOU. Exclusion criteria included age less than 18, initial admission to inpatient or discharge from the ED. All charts were reviewed via electronic medical records with data extracted by the study authors. Data collected included patient demographics, time of onset of pain, pain score reported out of 10, medical history including history of trauma, IVDA, cancer, prior back surgery, and imaging performed, disposition from the EDOU, and any procedural or surgical intervention performed within 30 days.
Descriptive statistics were used to review the demographic characteristics. Statistical analysis was performed using chi-square for nominal data and t-test for interval data. Univariate and
multivariate analysis was performed for statistical significance, p<0.05.
RESULTS AND DISCUSSIONDuring the study period, 280 ED patients were placed in
the EDOU for acute low back pain meeting the study criteria. Of these, only 106 (37.9%) of patients met at least 1 HEDIS criteria (+HEDIS), and 174 (62.1%) did not met any HEDIS criteria (-HEDIS). Demographically both groups were similar and characteristics are shown in Table (1). The mean age 58.5 years vs. 57.4 years (p=0.64), mostly female (66% vs. 63%, p=0.56) and white (65% vs. 67%, p=0.72) for the +HEDIS vs the -HEDIS patients. The average pain score was similar: +HEDIS 8.7 ±1.8 vs -HEDIS 8.7 ±2.2 (p=1.0) out of 10. 87 (82%) of the +HEDIS patients vs 126 (72.4%) of the -HEDIS had imaging performed during their ED or EDOU stay (p=0.07). The +HEDIS patients were statistically as likely as the -HEDIS patients to have an X-ray (43% vs. 41%, p=0.74), CT (18% vs. 19%, p=0.92), MRI (49% vs. 39%, p=0.08) and surgical consultation (64% vs 56%, p=0.16). The +HEDIS patients had no significant difference in procedural or surgical intervention performed within 30 days compared to the -HEDIS patients (22% vs. 16%, p=0.19).
Factors not related to current HEDIS criteria (Table 2) that were significantly associated with early intervention were pain score 10/10 (N=117, 22.7% intervention, p = 0.04) and history of back surgery (N=69, 30.4% intervention, p = 0.002). Patients with a duration of pain of 1 day or less were statistically less likely to need intervention, 9.0% vs 20.6% of patients with pain more than 1 day (p = 0.03). Pain duration of 1week, 1 month, and longer than 1 month were not associated with any statistically significant change in intervention rate.
Figure 3 Resource Utilization in Modified HEDIS Criteria score 2 or more with Pain 10/10Modified Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer, Personal History of Back Surgery.
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Table 1: Patients meeting HEDIS criteria. Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer.
Negative HEDIS Criteria
Positive HEDIS Criteria P value
Number 174 103GenderFemale 109 (62.6%) 70 (66.0%) 0.565
Table 2: Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, and Personal History of Cancer
Table 3: Analysis of intervention rates of possible Clinical Criteria Sets. Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer.
N Intervention Rate P value
Personal History of Back Surgery or
HEDIS Criteria
143 Positive 33 (23.1%)0.02137
Negative 17 (12.4%)
Pain 10/10 or HEDIS Criteria
211 Positive 37 (17.5%)0.8
69 Negative 13 (18.8%)Personal History of Back Surgery
or Pain 10/10 or HEDIS criteria
222 Positive 41 (18.5%)
0.658 Negative 9 (15.5%)
Analysis of several sets of clinical criteria was performed (Table 3) including the addition of back surgery to the current HEDIS criteria, the addition of pain 10/10 to the current criteria, and the addition of both history of back surgery and pain 10/10 to the current criteria. The proposed set of Modified HEDIS criteria including a history of back surgery to the current criteria (Table 4) resulted in 143 patients meeting Modified HEDIS criteria and 137 without Modified HEDIS criteria. Patients meeting the Modified HEDIS criteria had a significant difference in MRI utilization 48% vs 37%, (p=0.049), early intervention 24% vs 12% (p=0.02), and longer length of stay 2.0 ±2.6 days vs 1.2 ±1.3 days (p<0.01) respectively. The patients with the addition of Pain 10/10 to the current HEDIS criteria had no statistically significant difference in intervention rates; 17.5% in 211 patients (either +HEDIS or pain 10/10) vs 18.8% in 69 patients not meeting this criteria (-HEDIS and Pain <10/10) (p=0.8). The patients meeting criteria formed from the addition of both a history of back surgery and pain 10/10 to the current HEDIS criteria (+HEDIS or history of surgery or pain 10/10) were found to have an intervention rate of 18.5% (N=222) compared to 15.5% (N=58) in patients meeting none of the criteria (p=0.15).
A highest risk group was identified as having a Modified HEDIS score of 2 or more as well as Pain 10/10 considered separately. These 21 patients were found to have a highly significant intervention rate of 52.4% (p <0.000001) and length of stay of
Table 4: Analysis of Proposed Modified HEDIS Criteria. Modified Healthcare Effectiveness Data and Information Set (HEDIS) criteria: Recent Trauma, Intravenous Drug Use, Neurologic Deficit, Personal History of Cancer, or Personal History of Back Surgery.
N MRI Utiliza-tion Intervention Length of
Stay (days)
All negative 137 51 (37.2%) 17 (12.4%) 1.23 +/- 1.33
Any positive 143 68 (47.6%)p= 0.08
33 (23.1%)p= 0.02
1.94 +/- 2.65p= 0.005
Any positive with Pain
10/1075 36 (48.0%)
p= 0.119 (25.3%)
p= 0.021.87 +/- 3.06
p= 0.04
2 or more positive 45 27 (60.0%)
p= 0.00818 (40.0%)p < 0.0001
2.36 +/- 2.76p= 0.0003
2 or more positive with Pain 10/10
21 14 (66.7%)p=0.01
11 (52.4%)p < 0.000001
2.40 +/-3.13p=0.003
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2.40 +/- 3.13 days (p=0.003) when compared to patients with no Modified HEDIS criteria.
The results of this study indicate that the current HEDIS criteria are a poor indication of the need for utilization of resources in ED observation unit patients. Less than half of ED observation unit patients that underwent imaging for lower back pain met one or more HEDIS criteria, indicating that clinicians are more likely using other factors or simply clinical gestalt to guide their practice [14-16]. Although the HEDIS measures are designed to help clinicians by encouraging conservative management of lower risk patients, the current criteria are not designed to help guide management or timing of imaging and intervention. The current HEDIS criteria were not positively associated with early procedural or surgical intervention and in fact failed to correctly identify 16% of the patients that required early intervention.
Our data identified severe subjective back pain, rated 10 out of 10 at ED presentation, and a history of back surgery as factors not currently included in the HEDIS criteria that are positively associated with increased imaging utilization and early intervention while pain duration less than one day was associated with decreased need for early intervention.
In an effort to help predict which patients are more likely to require early procedural or surgical intervention as well as increased acute care resources, we proposed Modified HEDIS criteria including the addition of personal history of back surgery to the current HEDIS measures. The proposed Modified HEDIS Criteria was associated with increased MRI utilization, higher rates of early intervention, and longer length of hospital stay. In addition, patients with higher scores on the Modified HEDIS criteria and with severe back pain rated 10/10 were found to be at sequentially higher risk. Patients with higher risk scores are more likely to require extended hospital stays as well as substantially higher rates of intervention and should therefore be considered for hospital admission rather than observation.
This study provides insight into utilization of the ED and the ED observation unit, but it is not without its limitations. Although the data reviewed includes 30 day procedure and surgical intervention performed within the same hospital system, EMR limitations did not allow for review of records from outside hospitals or outpatient visits at physician offices. Similarly, it does not include further advanced imaging performed in outpatient follow-up. The data utilizes initial subjective pain scores which may change depending on each patient’s home medication use, chronic opioid use, and co morbid conditions. The Past Surgical History as taken from patients was not a standardized question, so some patients’ responses may not have included less invasive prior procedures such as epidural steroid injections or kyphoplasty.
Overall national ED and ED observation unit utilization and compliance with HEDIS measures are unknown, although these data indicate that further studies are needed to examine the current HEDIS measures before any quality initiative implementation. Further studies are also needed to help validate the Modified HEDIS criteria as well as to identify other factors that are associated with imaging utilization and early procedural
and surgical intervention in a manner to both decrease unneeded testing and excess cost as well as correctly identify patient’s in need of advanced imaging and early intervention.
CONCLUSIONLower back pain is a very common chief complaint for
patients presenting to the ED and ED observation unit and is associated with significant morbidity as well as healthcare costs associated with loss of productivity, return visits, advanced imaging, and procedural and surgical intervention. The Choosing Wisely Campaign established the HEDIS criteria as guidelines to help reduce unnecessary testing in acute low back pain in lower risk individuals, but these criteria do not address the need for testing in patients older than 50, patients with sub acute or chronic pain, or appropriateness of emergent testing in the ED or ED observation unit vs prompt testing to be completed on an outpatient basis. Our suggests that clinicians are using other criteria to help direct their workup and disposition as the current criteria failed to identify a significant number of patients who required procedural or surgical intervention within 30 days. Our data also suggests that the current HEDIS criteria may be improved to better predict longer length of stay, advanced imaging, and need for procedural or surgical intervention with the addition of a personal history of back surgery as well as a separate consideration for patients presenting with pain of 10/10 severity.
ACKNOWLEDGEMENTSWe would like to thank the nursing and support staff for
the Emergency Departments and Emergency Department Observation Units at both of our hospitals as well as Claire Pearson, MD and Michael Shaw, PhD.
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Jake Halvorsen GDO, Richmond L, Martus W, Pena M, Katherine Pitus DO, et al. (2017) HEDIS Criteria for Lower Back Pain and Early Intervention and Imaging Utilization in the Emergency Department Observation Unit. Arch Emerg Med Crit Care 2(2): 1023.
Cite this article
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